rehabilitation under fire - International Physicians for the Prevention

rehabilitation under fire
health care in Iraq 2003-7
enduring effects offc1
This report describes how the war and its aftermath continue to have a disastrous impact on
the physical and mental health of the Iraqi people, and the urgent measures needed to improve
health and health services. It focuses on the many failures of the occupying forces and their
governments to protect health, or to facilitate the rebuilding of a health system based on
primary health care principles. It assesses the current state of the health system, including the
impact of insecurity, and the workforce, supplies, medicines and equipment it lacks. It also
looks at health information and health policy. There is a special focus on mental health care, a
particularly neglected area. The report ends with conclusions and recommendations, exploring
what needs to happen now in Iraq and what lessons can be learned.
Keywords: conflict, security, health, health care, international development, Iraq
This report, an executive summary and other related information are available from the
Medact office and on the Medact web site – www.medact.org
Published In London, UK, 2008 by Medact
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© Medact 2008
Research and editorial team
Report published in
Dr Heba Al-Naseri, MBBS, BSc, general practitioner trainee
association with International
Ms Marion Birch, BA, MSc, SRN, SRM, director of Medact
Physicians for the
Dr Judith Cook, MB, BChir, DTM and H, Diploma in Development Studies, general practitioner; Medact board
Prevention of Nuclear War,
member; and member of the Medact working group on violence, conflict and health
of which Medact is the UK
Dr Jack Piachaud, BM, Bch, FRCPsych, psychiatrist; Medact board member; and member of the Medact
affiliate. IPPNW, the recipient
working group on violence, conflict and health
of the 1985 Nobel Peace
Ms Jane Salvage, RGN, BA, MSc, HonLLD, international health consultant and visiting professor, Florence
Prize, is located at 727
Nightingale School of Nursing and Midwifery, King’s College London, UK
Massachusetts Avenue,
Dr Sonali Sharma, MD, MSc, researcher in mental health and conflict
Cambridge, MA, USA,
tel +1 617 868 5050,
Advisers
fax +1 617 868 2560,
Dr Majid Alyassiri, MBCHB, FRCPsych, consultant psychiatrist, St George’s Hospital, London, UK
www.ippnw.org
Dr Olga Bornemisza, ME Des, MSc, Research Fellow, Conflict and Health Programme, London School of
Hygiene and Tropical Medicine, UK
The financial support of the
Ms Suzanne Fustukian, BA MSc Senior Lecturer, International Health, Institute for International Health and
Allan and Nesta Ferguson
Development, Queen Margaret University, Edinburgh, UK
Charitable Trust is gratefully
Professor Richard Garfield, RN, DrPH, manager, Health and Nutrition Tracking Service, Health Action in Crisis
acknowledged
Cluster, World Health Organization; and Henrik H. Bendixen Professor of Clinical International Nursing, School of
Nursing, Columbia University, New York, USA
Dr Ulrich Gottstein, retired professor of internal medicine, University of Frankfurt, Germany; co-founder,
IPPNW-Germany; retired IPPNW Vice-President, Europe; and member of frequent humanitarian missions to Iraq
Dr Ali Kubba, MB ChB, FRCOG, FFFP, consultant community gynaecologist and honorary senior lecturer, Guy's,
Kings and St Thomas' School of Medicine; and honorary professor, Basra School of Medicine, Iraq
Dr Sabah Sadik, MBCHB, FRCPsych, DPM, mental health adviser, Iraq
Professor Victor Sidel, MD, Distinguished University Professor of Social Medicine, Montefiore Medical
Center/Albert Einstein College of Medicine, New York, USA; and past president, International Physicians for the
Prevention of Nuclear War
Dr Egbert Sondorp, Senior Lecturer, Public Health and Humanitarian Aid, London School of Hygiene and
Tropical Medicine, UK
Professor Anthony Zwi, School of Public Health and Community Medicine and Associate Dean (International),
Faculty of Medicine, University of New South Wales, Sydney, Australia
Logistics and distribution Moyra Rushby, office manager, Medact
Design Sue MacDonald
Introduction
‘A little understood, unfamiliar war’
– US defence secretary Donald Rumsfeld,
resignation speech, November 8, 2006
Medact’s five earlier Iraq reports presented data on
health and health services, and thus helped to fill some
noteworthy gaps (Medact 2002, 2003, 2004; Yates
2005; Reif 2006). There has been a gradual and
welcome increase in such information from major
agencies including the World Health Organization
(WHO 2006a, 2006b), the International Committee
of the Red Cross (ICRC 2007) and Oxfam
(Oxfam/NCCI 2007). In this report Medact shifts its
focus to an assessment of the quality of the support
given to the Iraqi health system after the 2003
invasion.
WHO defines the ‘health system’ as all activities
whose primary purpose is to promote, restore or
maintain health (WHO 2000). This report does not
directly address the wider determinants of health,
such as the cost of living or food security, but this in
no way underestimates their importance.
WHO has highlighted the need to learn lessons from
post-conflict situations worldwide, and encourages us
to ‘share knowledge and experience (both of what
works and does not work) which can be widely
disseminated’. Despite the continuing conflict in Iraq,
it is important to start analysing why things happened
as they did; derive lessons for the future; and take
urgent measures to improve health and healthcare.
Post-conflict health sector rehabilitation is a
specialised area; this report aims to discuss its
principles, as applied to Iraq, with a wider audience.
Prepared by an independent team of researchers and
advisers from Iraq, the UK, the US and elsewhere, it
reviews developments in Iraq in the light of
international humanitarian law, and guidance on best
practice (for example, High-Level Forum on the
Health Millennium Development Goals 2005; Tayler
2005; WHO undated, accessed 2007).
The report starts with an update on the Iraqi health
system and its vulnerability. Five major aspects are
then considered: policy, human resources,
infrastructure, supplies, and health information. The
centre spread summarizes key issues. Although this
report does not focus on specific areas of health need,
we have made one exception: mental health. This
receives less attention than other health issues, yet its
long-term impact on a country’s future is profound.
Finally, we offer conclusions and recommendations.
A wide range of data has been reviewed (see page 13)
and many people were consulted. Security is a major
consideration for those working in and for Iraq today.
Some of those whose input shaped this report wish to
remain anonymous. Their contributions are as fully
appreciated as those from people who are named.
We wish to look to the future rather than apportion
blame. However, the avoidance of future ‘mistakes’
requires as a minimum an objective evaluation of why
best practice was frequently not followed in Iraq, and
in whose interests certain decisions were taken. We
hope this report contributes to that evaluation.
BOX 1 THE CONTEXT
Iraq today is a failing state with a complex health
emergency. Its government has neither authority,
credibility, administrative capacity nor ability to
impose and guarantee order (Dodge 2007, Iraq
Commission 2007). The country has fractured into
regional power bases with not ‘one’ civil war nor
‘one’ insurgency, but several (Stansfield 2007).
The state of health services reflects these regional
variations. In the Kurdish region of northern Iraq,
where the relatively safer conditions are often
popularly described in glowing terms, some
improvements have been made but the population
nevertheless still has no access to free, safe, high
quality health services.
The narratives about the attempts to rebuild the
health system are complex and conflicting. This is
partly due to the highly politicized context and the
large number of stakeholders, whose influence has
fluctuated. They include the Iraqi government(s); Iraqi
political, military, tribal and religious leaders; seven
ministers of health – both US and Iraqi nationals;
Iraqi nongovernmental organizations (NGOs),
including those in the diaspora; the governments,
civil servants and military leaders of the occupying
powers; foreign for-profit and nonprofit organizations
given reconstruction contracts; the UN and its
specialist organizations; international NGOs; and
other foreign interests. At the best of times it would
be difficult to devise and implement a rehabilitation
programme to engage all these stakeholders, and
these were hardly the best of times.
rehabilitation under fire
1
A health system under pressure
The demands on the Iraqi health system have
increased considerably since 2003, including trauma
and mental illness. Numerous reports document poor
and generally deteriorating health. Collection of
accurate health information is extremely difficult in a
country described as currently the most violent and
dangerous place on our planet (Global Peace Index
2007), but reputable studies suggest:
• High conflict-related mortality and morbidity (eg
Burnham et al 2006, UNICEF 2007).
• Death rates of children under five sliding towards
those of sub-Saharan Africa (Save the Children
2007).
• Eight million Iraqis in need of emergency aid
(Oxfam/NCCI 2007).
Against this backdrop, the provision of basic,
sustainable health services is very challenging. ‘Iraqi
hospitals are not equipped to handle high numbers of
injured people at the same time,’ says Dr Ali Haydar
Azize, Sadr City Hospital (IRIN 2007a). Junior staff
frequently perform procedures beyond their
competence (Iraqi Medical Association 2007), while
families usually provide nursing care. Professional
expertise is in even shorter supply in remote and rural
areas, and in primary health care. Many routine
treatments are not available, including for chronic
conditions like asthma and diabetes. Those who can
afford it travel abroad - often to Jordan or Syria - to
be treated at great risk and expense by Iraqi doctors
practising privately.
The duty of the state to meet this demand is
recognized in Iraq’s 2005 constitution: ‘The State
takes care of public health and provides the means of
prevention and treatment by building different types
of hospitals and medical institutions.’ However, the
obstacles are formidable.
The unregulated health economy, the need to
maximize
professional
income, and
the
individualistic, specialty-focused traditions of Iraqi
medicine are creating a fragmented fee-for-service
system mainly delivering curative care. This cannot
meet basic health needs effectively, and is beyond the
average citizen’s pocket.
The health-supporting infrastructure, already in a
fragile state following over 20 years of conflict and
sanctions, was severely damaged by the invasion and
subsequent looting. Despite some rehabilitation
efforts, the provision of health care has become
increasingly difficult since 2003. Doctors and nurses
have emigrated en masse, exacerbating existing staff
shortages. The health system is in disarray owing to
the lack of an institutional framework, intermittent
electricity, unsafe water supply, and frequent
violations of medical neutrality. The Ministry of
Health and local health authorities are mostly unable
to meet these huge challenges, while the activities of
UN agencies and nongovernmental organizations are
severely limited.
User fees were eliminated in 2003 in line with the
Coalition Provisional Authority’s initial policy of care
free at the point of delivery. They were quietly
reinstated, however, as the negative knock-on effects
of reduced flexible income on salaries and local
purchasing had not been anticipated. The total health
expenditure rose from US $23 per capita in 2003 to
$58 in 2004 (the latest year for which figures are
available), nearly half of it out-of-pocket payments
(WHO 2007a). The Ministry of Health was unable
to spend all of its budget in 2006-7 owing to
bureaucratic obstacles and difficulties with imports.
BOX 2 HAVING A BABY IN IRAQ
‘Aseel had been in labour for three days. It was
difficult for her, harder still with no pain-relief, doctor
or midwife. These were too expensive for us, but we
now had no other option.
‘After parting with my first banknote to secure petrol
from my neighbour, we prayed for safety during our
long trip to Diwaniyah Maternity Hospital in the dark.
Thankfully we arrived safely, and were greeted by
the open hand of the security guard. We parted with
another note to get in. It took a long time to find a
midwife. Eventually a sleepy midwife answered my
pleas, and we exchanged papers, notes and
promises to bring more notes. Amin, my first son,
was born next morning.
‘Aseel developed a serious kidney infection and
needed antibiotics, but we couldn’t get them in
Diwaniyah. Amin had to be fed powdered milk
diluted with tap water. There wasn’t enough money
to buy formula milk, so we had to make it last.
‘Amin survived one of the toughest milestones of his
life – birth. But by Iraqi standards his life of hardship
had just started.’
From a personal interview conducted in Diwaniyah, 2005
2
rehabilitation under fire
The failure to protect
The Geneva Conventions require the occupying
powers to ensure public order so they can fulfil the
following health-related responsibilities:
• Civilian hospitals should not be attacked and should
be respected and protected at all times (IV, Article 18).
• People engaged in the operation of civilian
hospitals should be protected (IV, Article 20).
• Health workers should be allowed to carry out
their duties (I, Article 19, and IV, Article 59).
• Consignments of medical stores and foodstuffs
should be allowed free passage (IV, Article 23).
• Health services, public health and hygiene should
be maintained (IV Article 56), including facilitating
assistance from relief agencies and other states (IV
Article 59).
actions must have come from a senior level (personal
communication).
After the transfer of authority to an interim Iraqi
government in 2004, the conflict was redefined as an
‘internationalized internal armed conflict’ (ICRC
2005). When occupying powers operate through a
newly appointed government, they are still
responsible as outlined above. Yet these rules and
obligations have routinely been ignored.
Violation of medical neutrality
Damage to health facilities
Health facilities were not protected during or after
the invasion. Approximately 7% of hospitals were
damaged initially (Garfield 2003) and 12% were
looted. Many ministry buildings were destroyed, and
only the ministries of oil and of the interior had
military protection (Medact 2003, Dodge 2007).
Looting and violence continued, usually unopposed,
and the damage and theft amounted in some areas to
a dismantling of health services. The country’s only
long-stay psychiatric hospital was one of the first to
be looted, and the patients ran away. Al-Kindi
Hospital, Baghdad, had ambulances and medicines
stolen at gunpoint. There are examples of local
action to prevent looting, suggesting that some of it
might have been stopped with decisive military
intervention (Bhattacharya 2003).
Restricted access to healthcare
facilities
No humanitarian corridor was provided during the
attacks on Fallujah in 2004, ambulances came under
fire and humanitarian convoys were denied access
(Doctors for Iraq 2005). Elsewhere checkpoints,
roadblocks and curfews have prevented health
workers and patients reaching health facilities, and
disrupted the distribution of supplies (Doctors for
Iraq 2006, IRIN 2007b). As such actions need the
coordination of several platoons, authority for such
Priority access to healthcare is sometimes
commandeered by powerful groups. Iraqi factions
have committed numerous violations of international
law, with patients’ relatives and insurgents demanding
treatment at gunpoint. Killings, kidnappings,
intimidation and abuse of staff by insurgent and
criminal gangs are widespread, and women health
workers in particular often stay home. An Iraqi whose
cousin was killed after being taken from his hospital
bed said: ‘We would prefer now to die instead of
going to the hospitals. The hospitals have become
killing fields’ (Paley 2006).
The takeover of healthcare facilities for military use
has deterred patients from using health services and
staff from going to work. Fallujah General Hospital
was occupied by Coalition forces during military
operations in 2004 (Seth et al 2006, Turlan and
Mofarah 2006). In April 2007, Iraqi soldiers beat up
staff at Al Numan, a Baghdad hospital serving mainly
Sunnis (Doctors for Iraq 2007). They claimed to be
under orders from the Ministry of Health.
Armed forces often provide ad hoc assistance to
civilians during conflict, but a more overt and
planned humanitarian involvement was undertaken
in an attempt to win hearts and minds in Iraq and
the US and UK electorates (Martins 2005, Seth et el
2006). Such efforts undermine coordinated efforts to
rebuild sustainable health services.
The exodus of Iraqi doctors and nurses is partly
attributable to poor security conditions and the
failure to protect (ICRC 2007). Iraq has also become
the world’s deadliest country for aid workers (Turlan
and Mofarah 2006). Most NGOs and international
organizations have left central and southern Iraq, or
work clandestinely or remotely through staff who
risk their lives daily.
There are many precedents for these problems, which
could and should have been anticipated
(Christodoulou 2007): ‘The failure to provide
adequate security is perhaps the single largest failure
of the reconstruction effort’ (Seth et al 2006). The
Geneva Conventions continue to be violated and the
humanitarian space has not been regained (Hansen
2004, Lafourcade 2005, Turlan and Mofarah 2006).
Lessons from previous conflicts were not applied, and
patients and health workers remain vulnerable and
fearful.
rehabilitation under fire
3
Health policy and planning
Health policy formulation in post-conflict settings
should follow some key principles:
• Preparedness: create flexible plans based on local
knowledge and understanding of previous policy,
to give direction and clarity in the confused postconflict situation.
• Relief and recovery: provide immediate relief, and
simultaneously plan for longer-term needs and
capacity-building.
• Participation: fully involve in-country leaders at all
levels, in partnership with humanitarian
organizations.
• Incrementalism: introduce agreed changes at a
speed the system can absorb.
These principles were generally ignored in Iraq, with
tragic consequences.
Prewar planning
Good practice in humanitarian assistance was
recognized before the invasion by the US State
Department, which warned of possible looting,
service breakdown and humanitarian catastrophe,
and stressed the need for rehabilitation and
surveillance (Hahn et al 2007, National Security
Archive 2007). But the internal US power struggle
that derailed these plans was not resolved before
deployment, and ‘caused great confusion in the field’
(Burkle and Noji 2004).
Bypassing State Department/USAID processes, and
sidelining relevant US and Iraqi expertise, the US
Defence Department secretly drew up its own plans
(Burkle et al 2007). It thought the infrastructure
would survive intact, and envisaged rapid
reconstruction carried out primarily by the private
sector and funded by oil revenues (Christodoulou
2007). The UN also worked on its own post-conflict
health plans, but these were largely ignored. UK
planning advice was not heeded.
After the invasion
WHO says post-conflict policy-makers should
maintain the health system’s basic functions, mending
the cracks and cautiously introducing innovations
(WHO undated, accessed 2007). This approach was
adopted in the very early days. Dr Frederick Burkle,
who led USAID’s prewar planning, became the first
Interim Minister of Health in April 2003, but was
replaced after two months by the less competent Jim
Haveman - a clear signal that politics took
precedence over expertise (Massing 2003,
Chandrasekaran 2006). External private contractors
4
rehabilitation under fire
were encouraged to rebuild Iraqi hospitals, while
other key policy concerns such as supporting health
workers received some resources but very limited
expert attention.
Invading Iraq without UN approval meant those
who knew most about postwar health planning were
mostly excluded from it in those early, critical
months. There was no meaningful debate, and full
Iraqi participation was lacking. The Pentagon had
virtual monopoly control of postwar reconstruction,
a position reinforced by the bombing of the UN’s
Baghdad headquarters in 2003, which triggered the
withdrawal of most UN development personnel. For
security reasons most UN programmes are still run
from neighbouring countries, except those in
northern Iraq. WHO’s Iraq office has five field offices
but its headquarters are in Jordan.
Contracts awarded by the US comprised the largest
aid package from a single country since the Marshall
Plan.Yet the CPA allocated only 4% of the US $18.4
billion Iraqi Relief and Reconstruction Fund to
health (Seth et al 2006), although it knew this budget
was inadequate (IRIN 2004).
Far bigger contracts were awarded to the private
sector than to expert health bodies like WHO,
UNICEF and nongovernmental humanitarian
organizations (Seth et al 2006). These included
contracts for training, capacity-building and
‘strengthening’ the Ministry of Health as well as for
physical reconstruction activities.
Meanwhile Iraqis had little opportunity to influence
the future of their health services. The enforced
sacking of Ba’ath party members (‘deBaathification’) removed many health experts from
senior posts, and clear and consistent leadership was
lacking. At local level there was little or no inclusive
policy-making or coordination with community
groups such as religious charities and mosques
(Hansen 2004, Lafourcade 2005, Turlan and Mofarah
2006). Successive Iraqi ministers of health indicated
commitment to rebuilding a primary care-led system
with guaranteed access for the poor, and health care
free at the point of delivery (WHO 2007c), but they
had little power to turn rhetoric into action.
Nearly five years after the invasion, Iraq still has no
comprehensive health policy or funding strategy. The
brief window of opportunity that opened after the
invasion was firmly closed by US military and
political conservatives, and remains closed today.
The health workforce
Rebuilding hospitals and health centres achieves little
without a parallel strategy to support the health
workers who staff them (WHO 2005). Good practice
requires the following:
• Respect for medical neutrality in accordance with
international law.
• A clear, comprehensive policy on human resources
for health.
• Improvements in pay, working conditions and
other incentives to retain and develop the
workforce.
• Raising standards of care through appropriate
regulatory systems, basic education and continuing
professional development.
• Relaunching professional associations and trade
unions as effective independent organizations.
Iraqi health workers are struggling against enormous
odds to keep the service going.The steady outflow of
professionals during the 1990s has turned into a
flood: up to 75% of doctors, pharmacists and nurses
have left their jobs since 2003, and over half of these
have fled abroad (ICRC 2007, IRIN 2007c, IRIN
2007d, Iraqi Medical Association 2007). This may
have left as few as 9000 doctors and 15,000 nurses
serving 28 million people, an extremely low
professional to population ratio. For every 10,000
citizens there are only six doctors (compared with 23
in the UK), 12 nursing staff (88 in the UK) and less
than one midwife (WHO 2007a, 2007b). Dentists,
pharmacists and managers are also in short supply.
Health professionals are almost completely absent
from remote and rural areas. They are also numbered
among the estimated 2.2 million internally displaced
people (UNHCR 2007).
The Ministry of Health and regional health
authorities face similar staff shortages. There has been
a rapid succession of health ministers since 2003 (the
post became vacant in April 2007 and remained so at
the time of writing), and a turnover of two-thirds of
the more senior civil servants in Baghdad and the
governorates. De-Baathification of the machinery of
government removed many experienced staff, and
the Ministry has only a quarter of its complement.
Those who remain face huge obstacles and in some
cases lack the capacity to lead policy development,
planning and implementation.
Training has also been severely disrupted. Medical
schools and colleges struggle to stay open and students
face many threats to their safety and educational
experience (Iraqi Medical Association 2007).This seed
corn - the country’s future health professionals - is not
being nurtured. Those who do qualify may not be
fully competent, yet continuing professional and career
development opportunities are few.The roles of nurses
and midwives are particularly poorly developed.
Piecemeal measures
Some measures were taken to tackle these issues,
including pay rises for many health workers.
Promising beginnings were also made on developing
policy on human resources for health. For example,
WHO and US nurses helped Iraqi counterparts to
formulate a national strategy for nursing and
midwifery in 2003 (Salvage 2007), but little further
progress was made. As security deteriorated, most
external assistance remains on hold, although some
training opportunities have been provided inside and
outside the country. WHO, for example, has trained
nearly 34,000 people (WHO 2006a). However, the
impact of short courses and study visits is often
unsustainable, while partnerships with overseas health
institutions that offer pockets of solidarity and
support struggle to survive.
In summary, this combination of events and
omissions is creating a poorly trained, overworked,
demoralized, fearful, underpaid health workforce in
Iraq. Despite their dedication, many have reached
breaking point. The implications are alarming. Iraqis
describe their health system as ‘beheaded’, because
many of its brightest and best have already migrated,
while the practitioners, managers and teachers of the
future are not being developed or supported.
B O X 3 L I G H T AT T H E E N D O F
THE TUNNEL?
There are occasional examples of successful health
service rehabilitation in Iraq – effective and potentially
sustainable because they adopt best practice
principles. They are characterized by a long history of
involvement in the country; partnership with state
health authorities to provide mainstream health
services; and the protection of local and tribal leaders.
Local contractors refurbish the facilities and local
health workers run the services, receiving training and,
just as importantly, moral support. Such projects work
closely with all relevant leaders, civil society,
universities and international partners to build the
alliances, trust and expertise that are the foundation
stones of post-conflict health systems development.
To protect their employees and patients, these projects cannot be
named here
rehabilitation under fire
5
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Health facilities and supplies
Re-establishing national supply and maintenance
systems post-conflict should not be neglected in favour
of delivering supplies and carrying out emergency
repairs. The key principles of best practice are:
• Balancing physical rehabilitation with the
development of the health workforce and supply
systems.
• Standardization of building design and equipment,
as part of a national plan for supply, repairs and
maintenance.
• Basing national plans for infrastructure and supplies
on a clear understanding of the context and
previous practice.
Rebuilding the infrastructure
Projects with rapid results and highly visible
‘deliverables’ (such as building new clinics) are
popular with parties to conflict and some donors, but
regarded with scepticism by others as the results are
often difficult to sustain or incorporate in a new
PHC-led health system. In Iraq, such projects
absorbed important resources inefficiently. Those
who understood the need for a system-wide
approach could not prevail over the political need for
visible results that would ‘brand the postwar
reconstruction efforts with the American flag’
(Denny 2003). The CPA, marginalizing Iraqi health
experts, thought there was no health infrastructure
worth preserving and no need to understand the old
system (Paterson 2006).
Large health contracts were awarded with great haste
and little consultation, and their implementation
lacked quality and local participation (Seth et al
2006, Special Inspector General for Iraq
Reconstruction 2007). For example, when 150 new
health centres were built in Kurdistan, the regional
director of health planning, Dr Lezgin Ahmed, said
he was consulted only about their location and
would have preferred rehabilitation of existing
facilities. Many were never finished because of
‘contractual problems’ (Chatterjee 2007). On the
other hand, work by local contractors in the southern
Marshlands produced good results – because it was
conducted in close consultation with local leaders,
was carefully supervised, and used relevant external
expertise.
Medical supplies
Before 2003 the Iraqi State Company for Marketing,
Drugs and Medical Appliances, Kimadia, supplied
medicines as part of the Oil-for-Food programme.
Despite concerns about its efficiency, it made low-
8
rehabilitation under fire
cost medicine available to those who needed it
(IRIN 2003). Objective assessment of the best way to
use this ‘ready-made distribution system’ (Neep
2003) was undermined by the US drive for
privatization. Colonel Scott Svabek, appointed
Kimadia’s chief operating officer, said in September
2003 that vaccines and rabies treatment shots were
‘new private contracts ready to go’ (IRIN 2003).
The national formulary – the list of drugs supplied by
the Ministry of Health – was reviewed, and the CPA
asked the US Defence Department to help improve
the quality and quantity of medicines (Basu 2004). It
did not seek help from WHO, whose model lists of
essential medicines are used by 80% of countries
worldwide (WHO 2007d). The number of items in
the existing formulary was reduced and the list
rebuilt to use more European and US suppliers (Basu
2004).
After the handover to the transitional government
the Ministry said 40% of the 900 essential drugs were
out of stock in hospitals, and 26 out of 32 drugs for
chronic diseases were unavailable (Chandrasekaran
2006). New health minister Aladin Alwan cancelled
the formulary revisions and encouraged local
pharmaceutical production. ‘We didn’t need a new
formulary. We needed drugs,’ he said. ‘But the
Americans did not understand that’ (Chandrasekaran
2006).
With growing insecurity, inefficient delivery systems,
an absence of regulation and a flourishing crossborder black market, drugs are often in short supply
or out of stock – especially higher-cost medicines
such as those for childhood leukaemia. The
prescription medicines that patients buy in their local
market are often counterfeit, adulterated or dateexpired – and expensive; but ‘desperate families buy
them in an attempt to save the lives of their loved
ones but thereby put them at high risk’, said Dr
Abdel-Razaq, a Baghdad oncologist (IRIN 2007e).
Day-to-day operational costs
In 2004 a request to reopen and top up the prewar
bank accounts of district health administrators was
refused as contrary to accounting procedures. These
still contained small but significant amounts that
could have been used for items such as generator
fuel. In the same year 13 Baghdad hospitals had 84%
of the ambulances they needed, only half of them in
working order (Jamail 2005). The importance of
fixing such deceptively minor problems was not
appreciated.
Health information
Postwar humanitarian and rehabilitation efforts fare
best when they are based on good local information.
The key principles of good practice are:
• Build on and strengthen the national health
information system.
• Collect and compare data from different sources to
create a full picture.
• Establish agreed indicators to use in smaller surveys,
whose findings can then be aggregated.
• Maximise resources for data collection through
good cooperation, particularly in insecure
environments.
Lack of coordination
Before 2003, health information on Iraq was already
under the spotlight because of global concern about
the impact of sanctions (Garfield 1999). Data sources
ranged from the national health information system
to small participative studies. In 2003 WHO had
enough information to assess what resources were
needed to help health facilities function again after
the conflict. Yet in the absence of effective
coordination many organisations conducted their
own local rapid needs assessments. Not all used the
same indicators, and the information was not pooled
effectively to create a robust overview (Pavagnani and
Colombo 2003). Some NGOs tried to discuss health
information indicators and improve local data
collection but such initiatives remained localised
(personal communication).
Soon after the invasion a large USAID contract was
awarded to Abt Associates for ‘health systems
strengthening’. It subcontracted the collection of
baseline data to Huffman and Carpenter, self-styled
‘wetland regulatory and hydrologic consultants’.
Their final report concentrated on sophisticated
information technology, without explaining how
health information would be collected until such a
system could be introduced (Koudry 2004).
Meanwhile WHO was developing its own project to
assess the national diseases surveillance system
(WHO 2004), a goal supported by the Ministry of
Health, which wanted to integrate reporting and data
collection in a modern system.
Another contract was given to RTI International,
a US non-profit research organization, to strengthen
primary health services. A workshop in 2006,
with Ministry and WHO participation, concluded
it was difficult to agree a comprehensive PHC
strategy without better data. Opportunities for
comprehensive, system-wide strengthening of the
health information system have dwindled as security
has deteriorated, including at the Ministry of Health.
Iraqi and foreign nationals have risked their lives
conducting household surveys.
The politics of information
Health information, especially mortality data,
continues to be a highly political issue because it is
an indicator of the suffering caused directly or
indirectly by the invasion and subsequent violence
and poverty. In the face of persistent US and UK
refusal to facilitate, collect or release accurate civilian
mortality figures, different organizations have used a
range of data collection methods. The varying results
obtained from robust, widely used methods such as
standard random cluster sampling (eg Roberts et al
2004, Burnham et al 2007) and systemized and
consistent data collection from media sources (eg
Dardagan et al 2006) have been disputed, and the
opportunity for constructive comparison of data
collected using different methods has not been taken.
Existing health information – such as that relating to
Iraqis who fled to other countries - has not always
been acted on. There was considerable preparation
for a ‘humanitarian emergency’ before the invasion,
but the emergency and huge displacement only took
place three years later following sustained insecurity
and lack of economic recovery. By this time it was an
indication of the failure to reconstruct Iraq, and
agencies had to campaign to draw attention to the
dire living conditions and health risks experienced by
many refugees and internally displaced people.
Missed opportunities
Emergencies always present an opportunity to start
anew, but it is essential to establish and work from a
baseline of existing information and knowledge.
There was some awareness of this in Iraq, but the
piecemeal contracting-out of projects, insufficient
engagement of local experts, lack of coordination,
and appointment of leaders with little relevant
experience or knowledge meant that the principles
were not put into practice. Health information has
become more rather than less political, and there is an
urgent need to strengthen the national health
information system, and to assess civilian mortality
rates throughout the conflict in a well-resourced,
independent study.
rehabilitation under fire
9
Mental health
War and insecurity have a major impact on mental
health (Murthy 2007). In particular they influence
the emotional and cognitive development of
children, and the well-being of people with severe
mental disorders. Violent conflict, witnessing
atrocities, loss of loved ones, political oppression,
torture, forced migration, poverty, family breakdown,
unemployment and social inequality create
vulnerability to psychosocial distress and mental
disorder, and reduce resilience in the population as a
whole (Abed 2005, Patel et al 2006).
All these preconditions have been present in Iraq for
many years, resulting in significant, well-documented
mental health problems (Ahmad et al 2007, Al-Jawadi
and Abdul-Rhman 2007, Al-Obaidy and Piachaud
2007). Most services are based in general hospitals in
Baghdad and three other cities; there are 23 hospitalbased mental health facilities, but no children’s or
community-based services, and many people receive
little or no expert care or support. There are only
two mental hospitals in the whole country, both in
Baghdad. The stigma associated with severe mental
disorders means that families may keep their ill or
disabled relatives hidden, sometimes neglected or
abused, and seek treatment only from traditional
sources. People with learning disabilities receive little
specialist help or support.
Mental health was identified as a priority by the
CPA, but only $2.5 million was initially earmarked,
around 1% of the health budget - although mental
illness usually accounts for 11% of the total disease
burden (Patel 2007). Despite the lack of funding
some progress was made (WHO 2006b). A WHO
conference in Cairo in 2003 reviewed the needs and
agreed priorities. Iraqi psychiatrist Dr Sabah Sadik
was seconded from the UK health service to work as
national mental advisor for the Ministry of Health in
2004. A multidisciplinary national mental health
council was formed, and conferences held in 2005
and 2006. A mental health strategy was developed
based on WHO principles.
Signs of progress
Significant efforts have been made to improve
facilities. The Ministry of Health has built eight
psychiatric units, WHO has built six, and others have
been rehabilitated. As a result there is a treatment
facility in each governorate. Some NGOs provide
limited services on limited budgets. Services are
developing in northern Iraq, but there has been little
progress in the central and southern regions. There
10
rehabilitation under fire
was tension between exiled professionals returning to
leadership positions, and Iraqi personnel who had
remained during the old regime; tension between
UK and US models of mental health care; and
criticism of the high cost of external training. Efforts
were made to tackle these complex issues, but
security, stigma and low priority remain overarching
obstacles.
The need to improve education and training,
especially for non-medical professionals, is acute.
Psychiatrists are in short supply and morale is low
among those who remain. A few training initiatives
have been conducted for psychiatrists, nurses,
physicians, psychologists, social workers and teachers,
mostly in neighbouring countries and recently in
Kurdistan. Training for psychiatrists was also given in
the UK and USA.
Key tasks
A nationwide psychiatric survey is set to generate
important new data that should underpin the key
tasks for the future:
• To develop locally and culturally sensitive policies
and services that will strengthen self-care and
community care, especially for psychological first
aid, through massive public education and
community-based initiatives, as well as national and
regional conferences in Iraq.
• To develop clear terms of reference for the
National Mental Health Council.
• To ensure there is a defined budget allocated to
mental health.
• To widen the professional base, training nurses,
social workers and psychologists and linking with
other community sectors. All require more
funding.
• To integrate mental health into primary care.
The primary requirement for mental well-being is
peace and stability, with useful employment and
engagement in positive social relationships. The key
players need better coordination, and capacitybuilding should empower and engage with
community leaders (IASC 2007). There is a need for
strong advocacy to ensure that mental health is truly
a priority. Both pre-existing problems and those that
emerge in relation to violent conflict need to be
tackled. The part played by the psychological
consequences of war in reinforcing cycles of violence
also needs examination.
Conclusions
Medact’s five earlier reports helped to fill some
noteworthy gaps by presenting data on health and
health services in Iraq. In the light of the welcome
recent increase in such information, this report has
assessed the support given to the health system after
the invasion.
The occupying forces failed to prevent the physically
and psychologically devastating looting of health
facilities. The Pentagon had assumed the
infrastructure would survive intact, and there were
not enough troops to control the situation fully. The
occupying powers stood back when the looting
started, and attempted to give it a positive spin as a
safety valve for popular discontent.
The dependence of the CPA on the military blurred
the distinctions between them, making some Iraqis
cautious about involvement. The ensuing reduction
in ‘humanitarian space’ weakened recognition of the
special status of health services and personnel in
conflict. This in turn created an environment in
which violations of the Geneva Conventions were
more likely.
Many of those who worked in Iraq with the CPA,
especially after the first few months, were appointed
for political rather than professional reasons. There
was also some reluctance to accept outside help.
Those who did have the requisite knowledge and
experience sometimes chose not to remain in post
due to the constraints they faced. Insecurity increased
and opportunities were lost before the transitional
government took over in 2004.
There was insufficient Iraqi participation in planning
and implementation. Some individual officials
worked hard to involve Iraqis, but others appeared
not to consider it a priority: ‘The Iraqis were very
much an afterthought from what I saw’ (Coxen,
quoted in Alderson 2007). No minister of health
stayed in post long enough to consolidate policy
direction, and some followed a factional agenda. This
key leadership post was vacant from April 2007 and
remained so at the time of writing.
The sequencing of projects should have been more
context-sensitive and less politically influenced.
‘Instead of beginning with security and basic needs
and attempting the more complex things later, we
implemented simultaneously programmes on human
rights, the free market, feminism, federalism, and
constitutional reform’ (Stewart 2007).
International evidence against applying free market
principles to the health sector, especially postconflict, was ignored. Talk of establishing a free
national health service had little practical linkage
with what was actually happening - de facto
privatization. Favourable contracts were awarded to
US companies, who were not held accountable for
poorly executed work. Much Iraqi money was
wasted during the first year after the invasion.
Competing agendas also affected the quality of
rehabilitation. The possibility of developing a clear
health plan was compromised by the desire to win
Iraqi hearts and minds, to create profit-making
opportunities for international business, and to play
to the political and public galleries outside Iraq.
The lack of an overall strategic plan on human
resources for health meant that development
initiatives took place in a vacuum. The limited
amount of training mainly raised morale and
extended professional contacts, rather than teaching
transferable skills.
In many instances no provision was made for the
maintenance of buildings and equipment, and there
were few operational budgets to cover running costs.
It was thought that a highly centralised health budget
could be protected more easily from corruption, but
it resulted in monies not reaching the point of use.
Proposals to improve the health information system
were too reliant on complex technology and too
complicated for the immediate post-conflict context,
when rapid data collection was needed for planning
and operations. WHO has subsequently assisted the
Ministry of Health to improve surveillance.
From soon after the invasion until today, good
practice in the health sector has been subordinated to
different political agendas. The pattern was set early
on by the CPA, derailing its own promising start. As
a senior official said: ‘You’re going to only have
enough to build an occasional clinic or school, and
you can connect them as you like to your political
programmes and objectives. Your budget is meant to
support your political work, not to provide the basis
for a full-scale development operation. Focus on
making us friends. We need them’ (quoted in Stewart
2007).
rehabilitation under fire
11
Recommendations
There are many lessons to be learned from Iraq. The
task is to analyse and disseminate them, while doing
everything possible to rehabilitate Iraq’s health
system. These recommendations aim to contribute to
this process.
Human resources
In the present insecure climate, health workers
urgently need imaginative and sensitive assistance
provided with donor funding through civil society,
local and international NGOs, the diaspora, and
institutional links.
Participation
Iraqis must define and lead all development processes
and must be equal partners in rehabilitation projects.
Greater local participation is essential for the future.
Coordination
All stakeholders, including Iraqi leaders and civil
society, diaspora groups, NGOs, international
agencies and donors, should be encouraged and
helped to coordinate their efforts.
Protection, medical neutrality and access
to services
The special role of health services and staff in times
of conflict, and how international humanitarian law
relates to them, should be discussed in appropriate
fora, including a working group representing the
Iraqi government, the former occupying powers, and
relevant actors from the Inter-Agency Standing
Committee (the primary mechanism for interagency coordination of humanitarian assistance,
involving key UN and non-UN partners). The
abuses of international law in Iraq need to be
objectively documented, and issues of accountability
addressed.
Useful specific lessons can be learned through an
evaluation of the various types of training that took
place within the country, in neighbouring countries
and further afield.
Infrastructure and supplies
No occupying power should be able to impose
neoliberal free market principles on the health sector,
and should not allow them to drive rehabilitation and
reconstruction. International norms should allow
local companies to have priority in any bidding
process for, say, a contract to build clinics. This would
be a more efficient and appropriate use of resources
and support the local economy.
Health policy
Health information
Various actors have tried to ensure that primary
health care services were a priority in terms
of attention and resources. However, insufficient
influence and lack of an overall policy to engage with
means this has not been realised in practice. This
priority needs to be taken forward both as part of an
overall policy debate and by making links with
initiatives such as the strategy for mental health
services.
Mortality and morbidity data need to be collected in
a coordinated and independent manner, and fed into
a revamped national health information system. The
minimum data set being developed with WHO
support should be finalised and widely publicised so
that all involved, including NGOs, use the same basic
indicators to collect relevant information.
Iraqi leaders, health experts and civil society should
determine what type of health system they want, on
the basis of their constitution. WHO should be given
greater internal and external support to facilitate this
process. Issues should include the national health
budget, the relationship with external donors and the
regulatory framework. This would contribute to
building and implementing a national health plan
(with rational budget) to fill the current policy
vacuum.
12
Investment in the health workforce has been well
intentioned but often short-term and fragmented.
The Ministry of Health should now lead the
development of a comprehensive human resources
strategy. This would relate the total human resource
requirement to needs, facilities, coverage and national
budgets, and would consider recruitment, retention
and education issues. The initiative should involve all
relevant stakeholders and could be facilitated or
supported by WHO.
rehabilitation under fire
Appeal to donors
Donors should continue to support ongoing
humanitarian efforts and projects in Iraq. There is a
common perception that the country is rich and
therefore not in need of funds, alongside a political
reluctance to acknowledge the ongoing humanitarian
crisis within its borders and among refugees in
neighbouring countries. As a result, potentially valuable
projects and local programmes are inadequately funded
to meet acute health needs in a hostile environment,
although many are small-scale and require only modest
funds. ‘Aid money can be spent effectively – and the
need is dire’ (Oxfam/NCCI 2007).
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International humanitarian law
Basic Principles on the Use of Force and Firearms by Law Enforcement
Officials (1990). Adopted by the Eighth United Nations
Congress on the Prevention of Crime and the Treatment of
Offenders, Havana, Cuba, 27 August-7 September.
Geneva Convention Relative to the Protection of Civilian Persons in
Time of War (1949). Reproduced by the Office of the High
Commissioner for Human Rights
http://www.unhchr.ch/html/menu3/b/92.htm
Protocol Additional to the Geneva Conventions (1949) relating to
the Protection of Victims of International Armed Conflicts
(Protocol 1) 8 June 1977, Part II: Wounded, sick and
shipwrecked, Section 1 – General Protection Article 12 –
Protection of medical units.
This report analyses from a public health perspective the impact of the 2003 war
on Iraq, and the country’s ensuing political and security crisis, on health and
health services. It builds on Medact’s previous widely read reports on health in
Iraq published in 2002-2006. Here the focus shifts to assessing the quality of
the support given to the Iraqi health system since the invasion in 2003.
The war and its aftermath continue to have a disastrous impact on the
physical and mental health of the Iraqi people. Urgent measures are needed
to improve health and health services. This report focuses on the many
failures of the occupying forces and their governments to protect health,
or to facilitate the rebuilding of a health system based on primary health care
principles. It is important to understand why these tragic mistakes happened as
they did, to mitigate their effects in Iraq, and to prevent from them happening
again elsewhere.
This report is produced by Medact, an organization of health professionals that
exists to highlight and take action on the health consequences of war, poverty
and environmental degradation and other major threats to global health. For
many years Medact has highlighted the impacts of violent conflict and weapons
of mass destruction and worked to improve the health of survivors of conflict.
This report, an executive summary and other information on health and
conflict can be found on the Medact web site (www.medact.org) and on the
web site of International Physicians for the Prevention of Nuclear War
(www.ippnw.org).
Photographers © Moises Saman//PANOS. A desperate mother searches for her two children after they
disappeared amid a gigantic fire at an illegal petrol station in central Baghdad.
© Kael Alford/PANOS. A pool of blood on the floor of the triage room at Saddam Medical City hospital, near
the front lines of fighting between US forces and Iraqi resistance fighters.
The Grayston Centre, 28 Charles Square, London N1 6HT, United Kingdom
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enduring effects of war
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